first rib mobilization in the treatment of thoracic outlet
TRANSCRIPT
University of North DakotaUND Scholarly Commons
Physical Therapy Scholarly Projects Department of Physical Therapy
2013
First Rib Mobilization in the Treatment of ThoracicOutlet SyndromeChad C. BoehmUniversity of North Dakota
Follow this and additional works at: https://commons.und.edu/pt-grad
Part of the Physical Therapy Commons
This Scholarly Project is brought to you for free and open access by the Department of Physical Therapy at UND Scholarly Commons. It has beenaccepted for inclusion in Physical Therapy Scholarly Projects by an authorized administrator of UND Scholarly Commons. For more information,please contact [email protected].
Recommended CitationBoehm, Chad C., "First Rib Mobilization in the Treatment of Thoracic Outlet Syndrome" (2013). Physical Therapy Scholarly Projects.521.https://commons.und.edu/pt-grad/521
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FIRST RIB MOBILIZATION IN THE TREATMENT OF THORACIC OUTLET SYNDROME
By
CHAD C BOEHM Bachelor of Science
University of North Dakota, 2009
A Scholarly Project Submitted to the Graduate Faculty of the
Department of Physical Therapy
School of Medicine
University of North Dakota
In partial fulfillment of the requirements for the degree of
Doctor of Physical Therapy
Grand Forks, North Dakota May, 2013
This scholarly project, submitted by Chad C Boehm in partial fulfillment of the requirements for the Degree of Doctor of Physical Therapy from the University of North Dakota, has been read by the Advisor and Chairperson of Physical Therapy under whom the work has been done and is hereby approved.
dclvuuruJ~ (Graduate School Advisor)
<~fb~ (Chairperson, Physical Therapy)
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PERMISSION
Title First Rib Mobilization in the Treatment of Thoracic Outlet Syndrome
Department Physical Therapy
Degree Doctor of Physical Therapy
In presenting this Scholarly Project in partial fulfillment of the requirements for a graduate degree from the University of North Dakota, I agree that the Department of Physical Therapy shall make it freely available for inspection. I further agree that permission for extensive copying for scholarly purposes may be granted by the professor who supervised my work or, in his/her absence, by the Chairperson of the department. It is understood that any copying or publication or other use of this Scholarly Project or part thereof for financial gain shall not be allowed without written permission. It is also understood that due recognition shall be given to me and University of North Dakota in any scholarly use which may be made of any material in this Scholarly Project.
Signature CU c£~/..:5i?-
Date
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TABLE OF CONTENTS
LIST OF FIGURES .............................................................................................................. v
LIST OF TABLES ............................................................................................................... v
ABSTRACT .................................................................................................................................................. vi
CHAPTER
I. BACKGROUND AND PURPOSE ................................................................ 1
II. CASE DESCRIPTION .. ............................................................................... 4
Examination, Evaluation and Diagnosis ................................................. 4
Prognosis and Plan of Care ...................................................................... 8
III. INTERVENTION ........................................................................................ 9
IV. OUTCOMES ............................................................................................. 13
V. DISCUSSION ............................................................................................ 15
Reflective Practice .................................................................................................... 17
APPENDIX A .................................................................................................................... 19
REFERENCES .................................................................................................................. 20
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LIST OF FIGURES
3-1. Upper trapezius stretch ........................................................................................ 10
3-2. Middle trapezius stretch ....................................................................................... 10
3-3. Scapular retraction with depression .................................................................... 10
LIST OF TABLES
2-1. Isometric motion resisted and associated nerve root of myotome assessment ....................................................................................... 5
2-2. Areas of bilateral stimulation with associated Cervical nerve root.. .................. 6
2-3. Reported sensitivity and specificityI7 with calculated positive and negative likelihood ratios for special tests performed during examination ....................................... 7
3-1. Adapted from Fuentes et al.18 ............................................................................... 9
4-1. Summary of long term and short terms goals which patient had met by discharge ......................................................... 13
4-2. Cost analysis of treatment provided .................................................................. 14
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ABSTRACT
Background and Purpose: Thoracic outlet syndrome (TOS) is one of the most controversial clinical entities in medicine. It encompasses three related syndromes: compression of the brachial plexus (neurogenic TOS), compression of the subclavian artery or vein (vascular TOS), and a non-specific or disputed type ofTOS.s Neurovascular compression may be observed most commonly in the interscalene triangle, but has also been described in the costoclavicular space and subcoracoid space.6 The purpose of this case study is to further explore the efficacy of manual therapy, specifically mobilization of the 1st rib, to relieve the symptoms of a 43 yearold female, suffering from TOS.
Case Description: The patient is a 43 year old female presenting with a tingling sensation around her left scapula and down her left arm after prolonged periods of relaxed sitting. Myotomes, dermatomes and reflexes were all negative, bilaterally. Adson's maneuver and Roos test were both negative.
Intervention: Moist hot pack and IFC were administered for 10 minutes for muscle relaxation. The patient was then asked to lay supine and her first ribs were palpated. A manual depression of the first rib was performed and repeated three times. This treatment was repeated six times over the course of two weeks, in addition to a home exercise program.
Outcomes: The patient was seen three times per week for two and a half weeks for a total of eight treatment sessions. During the course of treatment, the patient reported a significant decrease in the frequency and severity of her symptoms. Once the therapist felt the patient had met her clinical goals, she was discharged with instructions to follow-up if any symptoms reoccurred.
Discussion: This case study demonstrates manual depression of the 1st rib as an easy, effective option in the conservative management of thoracic outlet syndrome.
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Chapter I Background and Purpose
Thoracic outlet syndrome (TOS) is one of the most controversial clinical
entities in medicine. The incidence of TOS is reported to be approximately 8% of the
populationl and affects females more than males (between 4:1 and 2:1 ratios).l,2,3,4
Thoracic outlet syndrome encompasses three related syndromes:
compression of the brachial plexus (neurogenic TOS), compression of the subclavian
artery or vein (vascular TOS), and a non-specific or disputed type ofTOS.5
Neurovascular compression may be observed most commonly in the interscalene
triangle, but has also been described in the costoclavicular space and subcoracoid
space.6
Clinical features may include pain in the shoulder and neck region, which
radiates into the arm, paresis or paralysis of muscle innervated by branches of the
brachial plexus, loss of sensation, reduction of arterial pulses in the affected
extremity, ischemia, and/or edema6•
Neurogenic TOS (NTOS) is the most common form of thoracic outlet
syndrome, comprising well over 90% of all TOS patients7 and according to Hooper
et a/. B a majority of patients with neurogenic TOS can be expected to improve with
proper conservative treatment. However, Novak et a/. 9 found that poor outcomes to
conservative therapy were associated with obesity, worker's compensation, and
double crush pathology involving the carpal or cubital tunnels.
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In a recent review of 13 studies published between 1983 and 2001, Vanti et
aPO found good or very good results were achieved using conservative treatment in
76 to 100% of disputed neurogenic TOS patients at short-term follow-up (within a
month) and 59 to 88% after at least one year.
Conservative (non-operative) treatment of thoracic outlet syndrome has
included the use of nonsteroidal anti-inflammatory drugs to reduce pain and
inflammation.!l Injection of botulinum toxin into the anterior and middle scalenes
for temporary relief of pain and spasm resulting from neurovascular compression in
the thoracic outlet has also been investigated,12,13 Jordan et a/. 12 found 64% of
subjects had a minimum of 50% decrease in pain, numbness, and fatigue for at least
one month following injection.
Since one of the areas of neurovascular entrapment is the costoclavicular
space between the clavicle and first rib, it should logically follow that widening this
space would be advantageous. One such conservative method to achieve this would
be to use a mobilization to manually depress the first rib. However, research
supporting the use of manual therapy in the treatment of TOS is scarce.
Walsh (1994) reported the use of soft-tissue mobilization techniques for the
thoracic outlet along with a flexibility exercise program and posture modification
activities in patients with TOS. Over the course of 2 to 14 sessions (mean 10.5
sessions), 68.5% of his patients were asymptomatic, 10.5% obtained moderate
relief, 5.8% obtained no relief.14
Prost (1990) reported the use of active exercises to lower the first rib along
with Peet's exercises, strengthening of the posterior muscles of the spine, elevation
2
(' \ of the shoulder girdle, isometric exercises for serratus anterior and pectoralis
minor.1s Over the course of 8 to 30 sessions (mean 14 sessions), 70% of patients
obtained good results (negative clinical signs, negative Doppler exam), 10% of
patients obtained moderate results (symptoms improved or disappeared, but had
recurrences during work activities), and 20% of patients obtained poor results,ls
The purpose of this case study is to further explore the efficacy of manual
therapy, specifically mobilization of the 1st rib, to relieve the symptoms of a 43 year-
old female, suffering from TOS.
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Chapter 2 Case Description
The patient is a 43 year old female who presented with a tingling sensation
around her left scapula and down her left arm after prolonged periods of relaxed
sitting. At the time of the examination, the patient was employed at a local college
and reported this tingling sensation had become a problem at work. She reported at
times, her symptoms had gotten bad enough for her to temporarily lose sensation in
her fingertips.
The patient had recently had an MRI, which was largely unremarkable, but
indicated a minimal amount of stenosis of the C3, C4, C5 intervertebral foramina.
During observation, it was noted the patient had very good sitting posture
but upper trapezius tightness was evident. This was exaggerated during the course
of conversation when she began talking with her hands. At the time of examination,
the patient had full active range of motion of both upper extremities and cervical
spine. Symptoms were unable to be replicated with active or passive range of
motion of the cervical spine.
Passive accessory intervertebral movements of the cervical spine were
assessed with the patient in supine lying and the physical therapist cradling the
patient's head under the occiput. The motion of each cervical vertebra was assessed
for ease of motion as the patient's head was passively moved through rotation,
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bilateral side-bending, flexion and extension. The motion of each cervical vertebra
appeared normal.
Myotome testing, the assessment of the motor units innervated by a
particular nerve root, was assessed with the patient sitting upright at the end of the
assessment table. Resisted isometric contractions were performed as outlined in
TABLE 1. Weakness in a resisted isometric contraction indicates a positive finding
and thus, a compromised nerve root. All myotomes were negative, bilaterally.
Nerve Root Motion resisted C1 Head flexion C2 Lateral side-bending C3 Shoulder Elevation (Shrug) C4 Shoulder Abduction C5 Elbow Flexion C6 Elbow Extension C7 Thumb Extension C8 Finger Adduction
TABLE 2-1. IsometrIc motIOn reSIsted and assocIated nerve root of myotome assessment.
Dermatome testing, the assessment of cutaneous innervation of a particular
nerve root, was assessed with the patient sitting upright at the end of the
assessment table. The patient was then asked to close her eyes as cutaneous
stimulation was applied bilaterally to areas outlined in TABLE 2. As stimulation was
provided, the patient was asked to indicate whether stimulation felt similar or
different, comparing bilaterally. A perceived difference indicates a positive finding
and thus, a compromised nerve root. All dermatomes were negative, bilaterally.
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Nerve Root Area stimulated (bilaterally) Cl Crown of scalp C2 Temple area above ears C3 Lateral aspect of neck C4 Superior aspect of shoulder C5 Lateral aspect of deltoid C6 Lateral aspect of thumb C7 Posterior aspect of third digit C8 Medial aspect of little finger Tl Medial aspect of forearm T2 Medial Asgect of upper arm
TABLE 2-2. Areas of bilateral stimulation with associated Cervical nerve root.
Reflex testing, the assessment of a peripheral nerve and associated reflex
pathway, was performed for C6 and C7. Reflexive contraction of the biceps (C6) or
triceps (C7) indicates a negative finding and thus, intact reflex pathway. Reflexes of
C6 and C7 presented normal, bilaterally.
First thoracic nerve root stretch assesses dural irritation of the first thoracic
nerve root (Tl). This test was performed by having the patient abduct their arm to
90 degrees, flex their pronated forearm putting the hand behind the neck. This
action stretches the ulnar nerve and Tl nerve root. Pain into the scapular area or
arm indicates a positive test,16 First thoracic nerve root testing was negative,
bilaterally.
Two classic special tests for the presence of thoracic outlet syndrome are the
Roos test and Adson maneuver. In 2001, Gillard, et all7 assessed the clinical
contribution of these (and other) special orthopedic tests in the diagnosis of
thoracic outlet syndrome. Results relevant to this particular case study are outlined
in TABLE 3. The special tests in question were found to be relatively poor at either
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ruling in or ruling out the presence of thoracic outlet syndrome and were only
slightly more effective when combined.
Sensitivity Specificity (+) Likelihood (-) Likelihood Probability Ratio Ratio
Roos test 0.84 0.30 0.53 1.20 Useless Adson Maneuver 0.79 0.76 0.28 3.29
Adson + Roos 0.72 0.82 0.34 4.00 TABLE 2-3. Reported sensitivity and specificity17 with calculated positive and negative likelihood ratios for special tests performed during examination.
Roos test was performed with the patient sitting upright at the end of the
Small Small
assessment table. The patient was then asked to hold both shoulders in abduction to
90 degrees with both elbows bent to 90 degrees and repeatedly open and close her
hands for three minutes. This position is thought to compress the neurovascular
bundle under the pectoralis minor muscle. A positive finding is defined as a
replication of symptoms or abolition of radial pulse. Patient reported no replication
of symptoms while the physical therapist found no change in pulse quality.
Adson maneuver was performed by palpating the radial pulse at the left
wrist. The patient's shoulder was laterally rotated and extended by the examiner as
she was asked to rotate her head toward the test arm (to the left) and extend her
head. Finally, the patient was asked to take a deep breath and hold it. This is thought
to increase the tension of the anterior and middle scalene muscles, decreasing the
interscalene space, thus compressing the neurovascular bundle. A positive finding is
defined as the abolition of radial pulse. Patient suffered no loss of radial pulse.
Patient reported feeling her symptoms while sitting with her arms relaxed in
her lap during the examination. While her symptoms were exacerbated, we had her
lie on her back and performed manual traction of the cervical spine with a minimal
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relief of symptoms. This led us to believe her cervical stenosis was a contributor, but
not the primary cause of her symptoms.
The patient's description of her symptoms led us to believe thoracic outlet
syndrome was still a possible cause. However, with the exception of upper trapezius
tightness, the patient's posture was very good. This is contrary to a typical TOS
presentation as the patient will generally have a forward head, rounded shoulders
posture. In addition, our thoracic outlet special tests, ROM and neurological testing
were all negative. This led us to also suspect a possible muscular entrapment of the
suprascapular and/or dorsal scapular nerves in the upper trapezius muscle.
Plan of care would focus first on a relaxation of the upper and middle
trapezius musculature and home exercise program to strengthen scapular
stabilizers and promote scapular retraction with subsequent follow-up as to relief of
symptoms. If this treatment was ineffective, we shift our focus to treating the
suspected thoracic outlet syndrome utilizing the aforementioned exercise program
and manual therapy to relieve symptoms again, with subsequent follow-up.
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Chapter 3 Intervention
Since her sitting posture was adequate and thoracic outlet testing was
negative, we began by treating the assumed muscular entrapment of the nerves
coursing through her tight trapezius muscle. During the patient's initial visit, after
examination and evaluation was complete, we administered Interferential Current
(IFC) for musculoskeletal pain management and moist hot pack to the left upper and
middle trapezius for muscle relaxation.
In 2010, Fuentes et al,18 performed a systematic review of the literature to
determine the effectiveness of IFC in the management of musculoskeletal pain.
Fourteen studies were included in the analysis. These studies encompassed a wide
array of diagnoses treated with IFC, summarized in TABLE 3-1.
Number of Diagnoses Studies Included Treated
5 Low back pain 4 Knee Osteoarthritis 2 Fibromyalgia/myofascial pain 1 Jaw pain 1 Frozen shoulder pain 1 Bicipital tendinitis
TABLE 3-1. Adapted from Fuentes et al.1a
The results of the meta-analysis indicated the use of IFC alone for
musculoskeletal pain is not significantly better than placebo or other forms of
therapy (Le. manual therapy, traction, massage). However, the results of the meta-
analysis also indicate the use of IFC as a co-intervention to be significantly better
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than control and placebo for reducing chronic musculoskeletal pain at discharge and
at 3 months post-treatment, respectively.
The patient was also given a home exercise program including an upper
trapezius stretch, middle trapezius stretch and scapular retraction with depression
exercises (FIGURES 3-1, 3-2 and 3-3).
FIGURE 3-1. Upper trapezius stretch. FIGURE 3-2. Middle trapezius stretch.
FIGURE 3-3. Scapular retraction with depression.
At her next scheduled visit, patient reported a minimal improvement in
frequency and intensity of symptoms. This lead us to believe her stenosis may be a
greater contributor than anticipated, so we began with IFC and moist hot pack to
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upper and middle trapezius for 10 minutes for muscle relaxation. Static mechanical
traction was then applied to the cervical spine at 12 pounds for 8 minutes, in a
supine position.
In 2004, Taskaynatan et al.19 performed a randomized prospective trial to
investigate the effects of cervical traction in addition to exercise and hot pack
therapy in 40 people with thoracic outlet syndrome of non-defined type. The
participants were randomly divided into a control or treatment group. The control
group received hot pack therapy and an exercise program; the experimental group
received hot pack therapy, an exercise program, and cervical traction. Outcomes
measured consisted of provocative maneuvers. These included the Adson,
hyperabduction, hyperextension, Roos, costoclavicular, and Wright's maneuvers.
These outcomes were assessed after three weeks of intervention. A significant
difference in numbness scores was found between the groups, in favor of cervical
traction (80% versus 20%, P < 0.001).19
The patient reported an immediate relief of symptoms only slightly greater
than that of IFC and moist hot pack alone.
At her next visit, the patient again reported an overall minimal improvement
in frequency and intensity of symptoms. Negative results of the Adson maneuver
and Roos test ruled out neurovascular entrapment between the scalene muscles and
pectoralis minor muscle, respectively. However, an area of entrapment the author
failed to examine is a bony entrapment of the subclavian neurovascular bundle
between the 1st rib and clavicle.
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Moist hot pack and IFC were administered for 10 minutes for muscle
relaxation. The patient was then asked to lay supine and her first ribs were
palpated. It became evident her left first rib was elevated, when compared
bilaterally. A mobilization was then performed to depress the first rib.
To perform the first rib mobilization, the patient remained lying supine with
her head in the examiner's right hand. Examiner then palpated the left first rib and
passively side-bended the patient's head to the left to relieve any muscular tension
on the first rib. Patient was then asked to take a deep breath in and out. During
exhalation, the examiner applied pressure to depress the first rib, holding it in place
at the end of the exhalation. Then, holding the first rib in place, the patient was
asked to inhale and exhale deeply again. The examiner continued applying pressure
to hold the first rib in a position of relative depression during inhalation, and further
depressed the first rib as able during exhalation. This process was repeated three
times in two sets, for a total of six first rib depression mobilizations.
At her next treatment session, patient reported a significant improvement in
frequency and intensity of her symptoms. Since the patient had the best results with
moist hot pack and IFC followed by first rib depression mobilization, we continued
with this intervention method while adding light strengthening and exercises of the
scapular stabilizers.
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Chapter 4 Outcomes
The patient was seen three times per week for two and a half weeks for a
total of eight treatment sessions. During the final four treatment sessions, the
patient had reported her symptoms arose very infrequently. Additionally, when her
symptoms did arise, they were faint and short-lasting. This was reported
consistently over a week's worth of treatment, the patient had met all the goals we
had established after the initial examination and evaluation (TABLE 4-1), therefore
we felt we had done as much as we could with conservative treatment. The patient
was discharged with instructions to continue her home exercise program and follow
up if she experienced any recurrence of symptoms.
Length of goal
Long Term Following three weeks of PT intervention, patient will report working a full week without exacerbation of symptoms. Following one week of PT intervention, patient will report three
Short Term or fewer exacerbation of symptoms over the course of a workweek. Following one week of PT intervention, patient will demonstrate
Short Term independence in HEP to decrease the frequency and intensity of her symptoms.
TABLE 4-1. Summary of long term and short terms goals which patient had met by discharge.
Cost
As previously stated, the patient was seen for a total of eight treatment
sessions, which amounts to $661.50 of billable treatment time. Insurance was able
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n to pay 75% of this cost, which leaves $165.38 of out of pocket expense. A more
detailed cost analysis is provided in TABLE 4-2.
Treatment Reimbursement Times performed Total Evaluation $72.46 1 $72.46 Hot pack $5.45 8 $43.60
Estim (manual) $17.69 8 $141.52 Therex $29.58 8 $236.64
Manual Therapy $27.88 6 $167.28 Grand Total $661.50
Out-of-Pocket $165.38
TABLE 4-2. Cost analysis of treatment provided.
Additional costs typically associated with functional impairment were
negligible. She lived quite close to the therapy facility so travel expenses were low.
Additionally, the patient was able to continue contributing to the economy at large.
That is to say, she did not miss any days of work and continued to be an active
member of the community, going out to shop or buy gas, for example.
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Chapter 5 Discussion
The primary purpose of this study was to eva I uate the effectiveness of 1st rib
mobilization in the treatment of thoracic outlet syndrome in a symptomatic 43-
year-old female. At the conclusion of two and half weeks of an outpatient physical
therapy program including interferential current (lFC), moist hot pack (MHP),
manual therapy and therapeutic exercise, the patient reported a significant
reduction in the frequency and intensity of her symptoms. This reduction made the
patient's symptoms very manageable, allowing her to avoid the need for surgical
intervention. While literature investigating manual therapy in the treatment of
thoracic outlet syndrome is very limited, our results show a manual depression of
the 1st rib to be an easy, effective option in conservative management of thoracic
outlet symptoms.
A secondary purpose of this case study was to evaluate commonly used
orthopedic provocative maneuvers in assessing the presence of thoracic outlet
syndrome. As previously mentioned, Gillard, et all7 found two common orthopedic
tests, Roos test and Adson maneuver, to have very low sensitivity and specificity
when used individually (TABLE 4-1). Furthermore, their study found performing
Roos test and Adson's maneuver together actually decreased sensitivity and only
slightly increased specificity, meaning these two tests are virtually useless in
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determining the presence of thoracic outlet syndrome. The author was unaware of
these findings at the time of the initial evaluation.
These findings are particularly relevant to this case study as both
provocative maneuvers were performed and false negatives were attained. These
false negatives affected the clinical decision-making process of the author, thus
affecting the course of treatment. Subsequently, the patient was not provided the
highest quality care as she received treatment for conditions that were not
contributing to her symptoms. This means the patient, and the patient's insurance
provider, had paid for two treatment sessions the patient did not fully benefit from.
Had true positives been attained through provocative testing, quality care could
have been provided earlier, reducing total visits to six and decreasing the financial
burden to the patient and her health insurance provider.
As health care providers, our primary duty is to provide the highest quality
care available. This begins with accurate diagnoses. With regards to thoracic outlet
syndrome, current research and clinical experience both tell us the tests we
currently utilize are not working. Therefore, the development and evaluation of new
orthopediC maneuvers to assess the presence of thoracic outlet syndrome is an area
in need of further research.
Some limitations of this case report include the absence of a functional
assessment, the treatment of only one patient, and possible variations in the
performance of the afore-mentioned special tests. Thus, the findings of this case
report should be applied to the general public with caution.
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Contributions to Success
While we obtained good clinical outcomes, it is important to note additional
contributing factors, which led to those outcomes.
At her initial visit, she was visibly frustrated that her symptoms had gotten
so bad. This made her very motivated to continue her lifestyle in a pain-free manner
and thus, increased her compliance.
We were lucky in the fact our patient was very disclosing. She made a sincere
effort to tell us anything and everything she felt relevant to her condition so we
could make the best clinical decisions possible.
She was very inquisitive, asking about everything from the anatomy and
cause of her symptoms to why were performing each treatment selected. This not
only helped her understand what we were doing, it helped us become better
teachers / clinicians.
Lastly, and I feel most importantly, she was open-minded. This made
"selling" therapy services much easier, aiding in her willingness to participate in
treatment sessions and perform her home exercise program.
Reflective Practice
When reflecting upon the course of treatment with this particular patient,
two additions to the initial examination are identified as possible contributors to a
more effective therapy experience: A functional assessment and the costoclavicular
maneuver provocative test.
A commonly used functional assessment of the upper extremity is the
Disability of the Arm, Shoulder and Hand (DASH) Questionnaire (Appendix A). I
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The DASH is a 30-item questionnaire, which assesses function of the upper
extremity with respect to various activities of daily living (e.g. turning a key, making
a bed or carrying heavy objects) with an optional section assessing upper extremity
function during work and sports/performing arts. This questionnaire has proven to
be a valid and reliable method of quantifying upper extremity function. 20.21 The
DASH has a minimal detectible change of 10.5 pOints21 and a minimal clinically
important difference of 10.2 points.21
Where the Adson maneuver and Roos test assess neurovascular entrapment
between the scalene muscles and pectoralis minor muscle, respectively, the
costoclavicular maneuver assesses neurovascular entrapment between the clavicle
and 1st rib.
The costoclavicular maneuver is performed with the patient sitting upright at
the end of the examination table. From behind, the examiner manually depresses
and retracts the patient's shoulders, thus narrowing the costoclavicular space.
Plewa and Delinger22 found the costoclavicular maneuver to have a reasonable
false-positive rate (only 7%) when using pain to indicate a positive result.
This simple maneuver may have helped the therapists identify the
anatomical structures contributing to the patient's symptoms at the initial
examination. As a result, the therapists may have created a more focused plan of
care, returning the patient to optimal function in an abbreviated period of time.
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APPENDIX A
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DISABILITIES OF THE ARM, SHOULDER AND HAND
THE
INSTRUCTIONS
This questionnaire asks about your
symptoms as well as your ability to
perform certain activities.
Please answer every question, based
on your condition in the last week,
by circling the appropriate number.
If you did not have the opportunity
to perform an activity in the past
week, please make your best estimate
on which response would be the most
accurate.
It doesn't matter which hand or arm
you use to perform the activity; please
answer based on your ability regardless
of how you perform the task.
DISABILITIES OF THE ARMr SHOULDER AND HAND
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DISABILITIES OF THE ARM, SHOULDER AND HAND
NOT AT ALL SLIGHTLY MODERATELY QUITE EXTREMELY A BIT
22 . During the past week, to what extent has your arm, shoulder or hand problem interfered with your normal social activities with family, friends, neighbours or groups? (circle number) 1 2 3 4 5
NOT LIMITED SLIGHTLY MODERATELY VERY UNABLE AT ALL LIMITED LIMITED LIMITED
23. During the past week, were you limited in your work or other regular daily activities as a result of your arm, shoulder or hand problem? (circle number) 1 2 3 4 5
Please rate the severity of the following symptoms in the last week. (circle number)
NONE MILD MODERATE SEVERE EXTREME
24. Arm, shoulder or hand pain. 1 2 3 4 5
25 . Arm, shoulder or hand pain when you performed any specific activity. 1 2 3 4 5
26. Tingling (pins and needles) in your arm, shoulder or hand. 1 2 3 4 5
27. Weakness in your arm, shoulder or hand. 1 2 3 4 5
28. Stiffness in your arm, shoulder or hand. 1 2 3 4 5
SO MUCH NO MILD MODERATE SEVERE DIFFICULTY
DIFFICULTY DIFFICULTY DIFFICULTY DIFFICULTY THAT I CAN'T SLEEP
29. During the past week, how much difficulty have you had sleep,ing because of the pain in your arm, shoulder or hand? (circle number) 1 2 3 4 5
STRONGLY DISAGREE NEITHER AGREE AGREE STRONGLY DISAGREE NOR DISAGREE AGREE
30. I feel less capable, less confident or less useful because of my arm, shoulder or hand problem. (circle number) 1 2 3 4 5
DASH DISABILITY/SYMPTOM SCORE = [(sum of n responses) - 1] x 25, where n is equal to the number of completed responses. n
A DASH score may not be calculated if there are greater than 3 missing items.
DISABILITIES OF THE ARM, SHOULDER AND HAND
( WORK MODULE (OPTIONAL)
(
The following questions ask about the impact of your arm, shoulder or hand problem on your ability to work (including homemaking if that is your main work role) .
~ease indkate whatyourjob/work ~:~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
o I do not work. (You may skip this section.)
Please circle the number that best describes your physical ability in the past week. Did you have any difficulty:
NO MILD MODERATE SEVERE UNABLE DIFFICULTY DIFFICULTY DIFFICULTY DIFFICULTY
1. using your usual technique for your work? 1 2 3 4 5
2. doing your usual work because of arm, shoulder or hand pain? 1 2 3 4 5
~~
3. doing your work as well as you would like? 1 2 3 4 5 -.,.
4 . spending your usual amount of time doing your work? 1 2 3 4 5
SPORTS/PERFORMING ARTS MODULE (OPTIONAL)
The following questions relate to the impact of your arm, shoulder or hand problem on playing your musical instrument or sport r both. If you play more than one sport or instrument (or play both), please answer with respect to that activity which is most
important to you.
Please indicate the sport or instrument which is most important to you:
o I do not playa sport or an instrument. (You may skip this section.)
Please circle the number that best describes your physical ability in the past week. Did you have any difficulty:
NO MILD DIFFICULTY DIFFICULTY
1. using your usual technique for playing your instrument or sport? 1 2
2. playing your musical instrument or sport because of arm, shoulder or hand pain? 1 2
3. playing your musical instrument or sport as well as you would like? 1 2
4. spending your usual amount of time practising or playing your instrument or sport? 1 2
SCORING THE OPTIONAL MODULES: Add up assigned values for each response; divide by 4 (number of items); subtract 1; multiply by 25. 4,n optional module score may not be calculated if there are any missing items.
MODERATE SEVERE DIFFICULTY DIFFICULTY
3 4
3 4
3 4
3 4
UNABLE
5 .~
5 -'-
5 --
5
U
1M Institute I Research Excelle nce II for Work & Advancing Employee Health Health
© INSTITUTE FOR WORK & HEALTH 2006. ALL RIGHTS RESERVED.
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